The battlefields of the 20th century stimulated the progress of surgery and taught the surgeon innumerable lessons, which were subsequently applied in civilian practice. Regrettably, though, the principles of military surgery and casualty evacuation, which can be traced back to the Napoleonic wars, had to be learned over again.

World War I broke, quite dramatically, the existing surgical hierarchy and rule of tradition. No longer did the European surgeon have to waste his best years in apprenticeship before seating himself in his master's chair. Suddenly, young surgeons in the armed forces began confronting problems that would have daunted their elders. Furthermore, their training had been in “clean” surgery performed under aseptic conditions. Now they found themselves faced with the need to treat large numbers of grossly contaminated wounds in improvised theatres. They rediscovered debridement (the surgical excision of dead and dying tissue and the removal of foreign matter).

The older surgeons cried “back to Lister,” but antiseptics, no matter how strong, were no match for putrefaction and gangrene. One method of antiseptic irrigation—devised by Alexis Carrel and Henry Dakin and called the Carrel–Dakin treatment—was, however, beneficial, but only after the wound had been adequately debrided. The scourges of tetanus and gas gangrene were controlled to a large extent by antitoxin and antiserum injections, yet surgical treatment of the wound remained an essential requirement.

Abdominal casualties fared badly for the first year of the war, because experience in the utterly different circumstances of the South African War had led to a belief that these men were better left alone surgically. Fortunately, the error of continuing with such a policy 15 years later was soon appreciated, and every effort was made to deliver the wounded men to a suitable surgical unit with all speed. Little progress was made with chest wounds beyond opening up the wound even further to drain pus from the pleural cavity between the chest wall and the lungs.

Perhaps the most worthwhile and enduring benefit to flow from World War I was rehabilitation. For almost the first time, surgeons realized that their work did not end with a healed wound. In 1915 Robert Jones set up special facilities for orthopedic patients, and at about the same time Harold Gillies founded British plastic surgery in a hut at Sidcup, Kent. In 1917 Gillies popularized the pedicle type of skin graft (the type of graft in which skin and subcutaneous tissue are left temporarily attached for nourishment to the site from which the graft was taken). Since then plastic surgery has given many techniques and principles to other branches of surgery.

Incredible pictures reveal the pioneering plastic surgery carried out on First World War facial gunshot victim by leading British surgeon

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His is the face of one of the very bravest of our ancestors and his scars pay testament to the horrors he endured in the trenches of the Great War.
But staring back from the camera, the pictures also demonstrate the work of the pioneering British plastic surgeon who attempted to help some of the men get their lives back after they had suffered terrible injuries.
Dr Harold Gillies is renowned for developing the first skin grafting and plastic surgery techniques to treat the World War One soldiers left wounded with severe facial disfigurements.

The physician performed some 11,000 operations at the Queen's Hospital in Sidcup, Kent, between 1917 and 1925.
And Dr Harold Gillies work was so groundbreaking that he eventually received a knighthood in 1930.
Until now, however, very little has been known about the family stories behind the surgeon's work.
But on the 130th anniversary of the surgeon's birth and 95th anniversary of the Sidcup hospital where plastic surgery began, details of the pioneering surgery have been released online.
The records are an index of the 2,328 soldiers who were treated at The Queen’s Hospital during the war and in its aftermath, with information including their names, regiments, ranks and the injuries they sustained.
Debra Chatfield, family historian at findmypast.co.uk who are launching the files on their site, said Dr Harold Gillies work was inspiring: 'The medical world owes a great deal to Dr Gillies, as do those who were treated by him in the early twentieth century and anyone who has ever received plastic surgery treatment since then.
'Without his pioneering developments in this field, plastic surgery might not be as advanced as it is today.
'These records are an important source of information for historians, the medical world and those interested in learning about the reality and aftermath of World War I.'

Due to the sensitive nature of some of the medical information, many of the hospital records and individual photographs will not be published online.
However, those whose ancestors were injured in the First World War and underwent surgery can search the collection to see if they received treatment from Dr Gillies’ team.
The index makes for fascinating reading, as it conveys the extent of facial disfigurements suffered by some soldiers and shows how quickly life could change for a soldier in the First World War.
One patient who can be found in the records was Richard Walker, a Private in the Royal Lancaster Regiment of the British contingent, 3rd battalion.
Aged only 20 years old, he was wounded on 23rd October 1918 and admitted to The Queen’s Hospital with a ‘gunshot wound lower lip’ – a severe disfigurement that would require specialist attention if he were to go on to lead a ‘normal’ life again.
Another example is William M. Spreckley, a Lieutenant from the Sherwood Foresters Service in the British contingent, 16th battalion.

He was Gillies’ 132nd patient and was admitted to the hospital in January 1917 at the age of 33 with a ‘gunshot wound nose’.
It was three-and-a-half years before doctors were able to discharge him in October 1920.
Dr Sam Alberti, Director of Museums & Archives at the Royal College of Surgeons, said the British surgeon was a 'founding figure in the history of plastic surgery':
'(He developed) innovative procedures to help reconstruct the faces of badly injured soldiers and airmen, whose facial injuries were caused by bullet wounds and flying shrapnel and needed extensive bone, muscle and skin grafting to restore their appearance.
'Most notably, Gillies introduced the tubed pedicle which used the patients’ own tissue to aid reconstructive surgery and reduce the chance of rejection.
'The files associated with his work are an unparalleled resource for the study of this important branch of medicine and family history.'

Amid the horrors of World War I, a corps of artists brought hope to soldiers disfigured in the trenches

Wounded tommies facetiously called it "The Tin Noses Shop." Located within the 3rd London General Hospital, its proper name was the "Masks for Facial Disfigurement Department"; either way, it represented one of the many acts of desperate improvisation borne of the Great War, which had overwhelmed all conventional strategies for dealing with trauma to body, mind and soul. On every front—political, economic, technological, social, spiritual—World War I was changing Europe forever, while claiming the lives of 8 million of her fighting men and wounding 21 million more.

The large-caliber guns of artillery warfare with their power to atomize bodies into unrecoverable fragments and the mangling, deadly fallout of shrapnel had made clear, at the war's outset, that mankind's military technology wildly outpaced its medical: "Every fracture in this war is a huge open wound," one American doctor reported, "with a not merely broken but shattered bone at the bottom of it." The very nature of trench warfare, moreover, proved diabolically conducive to facial injuries: "[T]he...soldiers failed to understand the menace of the machine gun," recalled Dr. Fred Albee, an American surgeon working in France. "They seemed to think they could pop their heads up over a trench and move quickly enough to dodge the hail of bullets."

Writing in the 1950s, Sir Harold Gillies, a pioneer in the art of facial reconstruction and modern plastic surgery, recalled his war service: "Unlike the student of today, who is weaned on small scar excisions and graduates to harelips, we were suddenly asked to produce half a face." A New Zealander by birth, Gillies was 32 and working as a surgeon in London when the war began, but he left shortly afterward to serve in field ambulances in Belgium and France. In Paris, the opportunity to observe a celebrated facial surgeon at work, together with the field experience that had revealed the shocking physical toll of this new war, led to his determination to specialize in facial reconstruction. Plastic surgery, which aims to restore both function and form to deformities, was, at the war's outset, crudely practiced, with little real attention given to aesthetics. Gillies, working with artists who created likenesses and sculptures of what the men had looked like before their injuries, strove to restore, as much as possible, a mutilated man's original face. Kathleen Scott, a noted sculptress and the widow of Capt. Robert Falcon Scott of Antarctica fame, volunteered to help Gillies, declaring with characteristic aplomb that the "men without noses are very beautiful, like antique marbles."

While pioneering work in skin grafting had been done in Germany and the Soviet Union, it was Gillies who refined and then mass-produced critical techniques, many of which are still important to modern plastic surgery: on a single day in early July 1916, following the first engagement of the Battle of the Somme—a day for which the London Times casualty list covered not columns, but pages—Gillies and his colleagues were sent some 2,000 patients. The clinically honest before-and-after photographs published by Gillies shortly after the war in his landmark Plastic Surgery of the Face reveal how remarkably—at times almost unimaginably—successful he and his team could be; but the gallery of seamed and shattered faces, with their brave patchwork of missing parts, also demonstrates the surgeons' limitations. It was for those soldiers—too disfigured to qualify for before-and-after documentation—that the Masks for Facial Disfigurement Department had been established.

"My work begins where the work of the surgeon is completed," said Francis Derwent Wood, the program's founder. Born in England's Lake District in 1871, of an American father and British mother, Wood had been educated in Switzerland and Germany, as well as England. Following his family's return to England, he trained at various art institutes, cultivating a talent for sculpture he had exhibited as a youth. Too old for active duty when war broke out, he had enlisted, at age 44, as a private in the Royal Army Medical Corps. Upon being assigned as an orderly to the 3rd London General Hospital, he at first performed the usual "errand-boy-housewife" chores. Eventually, however, he took upon himself the task of devising sophisticated splints for patients, and the realization that his abilities as an artist could be medically useful inspired him to construct masks for the irreparably facially disfigured. His new metallic masks, lightweight and more permanent than the rubber prosthetics previously issued, were custom designed to bear the prewar portrait of each wearer. Within the surgical and convalescent wards, it was grimly accepted that facial disfigurement was the most traumatic of the multitude of horrific damages the war inflicted. "Always look a man straight in the face," one resolute nun told her nurses. "Remember he's watching your face to see how you're going to react."

Wood established his mask-making unit in March 1916, and by June 1917, his work had warranted an article in The Lancet, the British medical journal. "I endeavour by means of the skill I happen to possess as a sculptor to make a man's face as near as possible to what it looked like before he was wounded," Wood wrote. "My cases are generally extreme cases that plastic surgery has, perforce, had to abandon; but, as in plastic surgery, the psychological effect is the same. The patient acquires his old self-respect, self assurance, self-reliance,...takes once more to a pride in his personal appearance. His presence is no longer a source of melancholy to himself nor of sadness to his relatives and friends."

Toward the end of 1917, Wood's work was brought to the attention of a Boston-based American sculptor, inevitably described in articles about her as a "socialite." Born in Bryn Mawr, Pennsylvania, Anna Coleman Watts had been educated in Paris and Rome, where she began her sculptural studies. In 1905, at the age of 26, she had married Maynard Ladd, a physician in Boston, and it was here that she continued her work. Her sculptural subjects were mostly decorative fountains—nymphs abounding, sprites dancing—as well as portrait busts that, by today's tastes, appear characterless and bland: vaguely generic portraits of vaguely generic faces. The possibility of furthering the work by making masks for wounded soldiers in France might not have been broached to Ladd but for the fact that her husband had been appointed to direct the Children's Bureau of the American Red Cross in Toul and serve as its medical adviser in the dangerous French advance zones.

In late 1917, after consultation with Wood, now promoted to captain, Ladd opened the Studio for Portrait Masks in Paris, administered by the American Red Cross. "Mrs. Ladd is a little hard to handle as is so often the case with people of great talent," one colleague tactfully cautioned, but she seems to have run the studio with efficiency and verve. Situated in the city's Latin Quarter, it was described by an American visitor as "a large bright studio" on upper floors, reached by way of an "attractive courtyard overgrown with ivy and peopled with statues." Ladd and her four assistants had made a determined effort to create a cheery, welcoming space for her patients; the rooms were filled with flowers, the walls hung with "posters, French and American flags" and rows of plaster casts of masks in progress.

The journey that led a soldier from the field or trench to Wood's department, or Ladd's studio, was lengthy, disjointed and full of dread. For some, it began with a crash: "It sounded to me like some one had dropped a glass bottle into a porcelain bathtub," an American soldier recalled of the day in June 1918 on which a German bullet smashed into his skull in the Bois de Belleau. "A barrel of whitewash tipped over and it seemed that everything in the world turned white."

Stage by stage, from the mud of the trenches or field to first-aid station; to overstrained field hospital; to evacuation, whether to Paris, or, by way of a lurching passage across the Channel, to England, the wounded men were carried, jolted, shuffled and left unattended in long drafty corridors before coming to rest under the care of surgeons. Multiple operations inevitably followed. "He lay with his profile to me," wrote Enid Bagnold, a volunteer nurse (and later the author of National Velvet), of a badly wounded patient. "Only he has no profile, as we know a man's. Like an ape, he has only his bumpy forehead and his protruding lips—the nose, the left eye, gone."